Invasive sino-orbital fungal infections in immunocompetent patients: a clinico-pathological study

Abstract

Objective: Invasive sino-orbital fungal infections in immunocompetent patients are a rare clinical entity; the diagnosis and management of which is challenging. We present a large case series of invasive sino-orbital fungal granulomas in patients without pre-existing systemic immunocomprimising condition. Design: Retrospective case series. Participants: Twenty cases of invasive sino-orbital/naso-orbital fungal granulomas in immunocompetent individuals. Methods: We retrospectively analyzed all patients with orbital fungal granuloma who were treated at a tertiary referral eye center in South India between January 2005 and December 2012. Histopathologic confirmation of tissue invasion by fungal elements and presence of granulomatous inflammation was established in all cases included in the study. Main outcome measures: Relief of patient symptoms, resolution/no progression of disease on orbital imaging, ocular, and vision salvage were the treatment outcomes studied. Results: Twenty patients (11 male and 9 female) were studied. Mean age of patients was 47.4 years ranging from 24–65 years. Aspergillus was the causative fungus in 18 cases while 2 were cases of mucormycosis. Surgical debulking of the orbital disease was performed in 7 patients. Exenteration was performed in 2 patients to prevent spread to the CNS. Medical therapy consisted of oral itraconazole in all patients and intravenous amphotericin B was administered in 2 patients. Average duration of medical therapy required to achieve relief from symptoms was 6–8 months. Recurrences are common and long-term follow-up is essential. Conclusions: Orbital fungal infections are challenging in terms of both diagnosis and treatment. Debulking along with prolonged antifungal therapy seems to be effective in controlling the infection.